N.M. Stat. § 30-44-7 (2026)

A. Medicaid fraud consists of:

       (1)      paying, soliciting, offering or receiving:

           (a) a kickback or bribe in connection with the furnishing of treatment, services
or goods for which payment is or may be made in whole or in part under the program,
including an offer or promise to, or a solicitation or acceptance by, a health care official
of anything of value with intent to influence a decision or commit a fraud affecting a
state or federally funded or mandated managed health care plan;

             (b) a rebate of a fee or charge made to a provider for referring a recipient to a
provider;

          (c) anything of value, intending to retain it and knowing it to be in excess of
amounts authorized under the program, as a precondition of providing treatment, care,
services or goods or as a requirement for continued provision of treatment, care,
services or goods; or
           (d) anything of value, intending to retain it and knowing it to be in excess of
the rates established under the program for the provision of treatment, services or
goods;

       (2)  providing with intent that a claim be relied upon for the expenditure of
public money:

             (a) treatment, services or goods that have not been ordered by a treating
physician;

         (b) treatment that is substantially inadequate when compared to generally
recognized standards within the discipline or industry; or

             (c) merchandise that has been adulterated, debased or mislabeled or is
outdated;

        (3)    presenting or causing to be presented for allowance or payment with
intent that a claim be relied upon for the expenditure of public money any false,
fraudulent, excessive, multiple or incomplete claim for furnishing treatment, services or
goods; or

       (4)      executing or conspiring to execute a plan or action to:

           (a) defraud a state or federally funded or mandated managed health care plan
in connection with the delivery of or payment for health care benefits, including
engaging in any intentionally deceptive marketing practice in connection with proposing,
offering, selling, soliciting or providing any health care service in a state or federally
funded or mandated managed health care plan; or

            (b) obtain by means of false or fraudulent representation or promise anything
of value in connection with the delivery of or payment for health care benefits that are in
whole or in part paid for or reimbursed or subsidized by a state or federally funded or
mandated managed health care plan. This includes representations or statements of
financial information, enrollment claims, demographic statistics, encounter data, health
services available or rendered and the qualifications of persons rendering health care or
ancillary services.

   B. Except as otherwise provided for in this section regarding the payment of fines by
an entity, whoever commits medicaid fraud as described in Paragraph (1) or (3) of
Subsection A of this section is guilty of a fourth degree felony and shall be sentenced
pursuant to the provisions of Section 31-18-15 NMSA 1978.

   C. Except as otherwise provided for in this section regarding the payment of fines by
an entity, whoever commits medicaid fraud as described in Paragraph (2) or (4) of
Subsection A of this section when the value of the benefit, treatment, services or goods
improperly provided is:
      (1)     not more than one hundred dollars ($100) is guilty of a petty misdemeanor
and shall be sentenced pursuant to the provisions of Section 31-19-1 NMSA 1978;

       (2)    more than one hundred dollars ($100) but not more than two hundred fifty
dollars ($250) is guilty of a misdemeanor and shall be sentenced pursuant to the
provisions of Section 31-19-1 NMSA 1978;

       (3)    more than two hundred fifty dollars ($250) but not more than two thousand
five hundred dollars ($2,500) is guilty of a fourth degree felony and shall be sentenced
pursuant to the provisions of Section 31-18-15 NMSA 1978;

      (4)    more than two thousand five hundred dollars ($2,500) but not more than
twenty thousand dollars ($20,000) shall be guilty of a third degree felony and shall be
sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978; and

      (5)    more than twenty thousand dollars ($20,000) shall be guilty of a second
degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15
NMSA 1978.

   D. Except as otherwise provided for in this section regarding the payment of fines by
an entity, whoever commits medicaid fraud when the fraud results in physical harm or
psychological harm to a recipient is guilty of a fourth degree felony and shall be
sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.

   E. Except as otherwise provided for in this section regarding the payment of fines by
an entity, whoever commits medicaid fraud when the fraud results in great physical
harm or great psychological harm to a recipient is guilty of a third degree felony and
shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.

    F. Except as otherwise provided for in this section regarding the payment of fines by
an entity, whoever commits medicaid fraud when the fraud results in death to a recipient
is guilty of a second degree felony and shall be sentenced pursuant to the provisions of
Section 31-18-15 NMSA 1978.

   G. If the person who commits medicaid fraud is an entity rather than an individual,
the entity shall be subject to a fine of not more than fifty thousand dollars ($50,000) for
each misdemeanor and not more than two hundred fifty thousand dollars ($250,000) for
each felony.

    H. The unit shall coordinate with the human services department [health care
authority department], department of health and children, youth and families department
to develop a joint protocol establishing responsibilities and procedures, including prompt
and appropriate referrals and necessary action regarding allegations of program fraud,
to ensure prompt investigation of suspected fraud upon the medicaid program by any
provider. These departments shall participate in the joint protocol and enter into a
memorandum of understanding defining procedures for coordination of investigations of
fraud by medicaid providers to eliminate duplication and fragmentation of resources.
The memorandum of understanding shall further provide procedures for reporting to the
legislative finance committee the results of all investigations every calendar quarter. The
unit shall report to the legislative finance committee a detailed disposition of recoveries
and distribution of proceeds every calendar quarter.

History: Laws 1989, ch. 286, § 7; 1997, ch. 98, § 3; 2003, ch. 291, § 1.

                                    ANNOTATIONS

Bracketed material. — The bracketed material was inserted by the compiler and is not
part of the law. Laws 2023, ch. 205, § 16 provided that references to the human
services department shall be deemed to be references to the health care authority
department.

Cross references. — For the children, youth and families department, see 9-2A-1
NMSA 1978 et seq.

For the legislative finance committee, see 2-5-1 NMSA 1978.

The 2003 amendment, effective July 1, 2003, added Subsection H.

The 1997 amendment, effective June 20, 1997, in Subsection A, added the language
beginning "including an offer or promise to" at the end of Subparagraph (1)(a), added
Paragraph (4), and made related stylistic changes throughout the subsection; added
"Except as otherwise provided for in this section regarding the payment of fines by an
entity" at the beginning of Subsection B; in Subsection C, added "Except as otherwise
provided for in this section regarding the payment of fines by an entity" at the beginning
of the introductory language, added the language beginning "and shall be sentenced" at
the end of Paragraph (1), inserted "dollars" in Paragraph (2), and substituted "Section
31-18-15 NMSA 1978" for "Section 31-19-1 NMSA 1978" in Paragraph (3); added
"Except as otherwise provided for in this section regarding the payment of fines by an
entity" at the beginning of Subsections D and E; and added Subsections F and G.

Materiality element of Medicaid fraud. — Section 30-44-7(A)(3) imposes a materiality
element, which requires that the false or fraudulent certification be integral to the
government’s payment decision; regulatory deficiencies that are not material to
government payment do not support a cause of action of Medicaid fraud under the
Medicaid Fraud Act. State ex rel. King v. Behavioral Home Care, Inc., 2015-NMCA-035,
cert. granted, 2014-NMCERT-008.

Where Medicaid provider failed to comply with criminal history screening requirements
of its caregivers, the state could not allege that the government could withhold payment
solely because the unscreened caregivers had disqualifying criminal convictions in their
histories, and therefore the fact that the Medicaid provider violated the statutory hiring
requirements does not create a violation of a condition of Medicaid payment that
supports a Medicaid fraud cause of action under the Medicaid Fraud Act. State ex rel.
King v. Behavioral Home Care, Inc., 2015-NMCA-035, cert. granted, 2014-NMCERT-
008.

Medicaid fraud not a lesser included offense of tampering with public records. —
Defendant charged with tampering with public records based on his sale of medicaid
cards to undercover agents was not entitled to an instruction on medicaid fraud as a
lesser included offense. State v. Dartez, 1998-NMCA-009, 124 N.M. 455, 952 P.2d 450,
cert. denied, 124 N.M. 311, 950 P.2d 284.